Acute kidney injury (AKI) is common among COVID-19 patients in the intensive care unit (ICU), and it is challenging to manage. The American Society of Nephrology (ASN) recently conducted a webinar on the topic with recommendations for in-hospital management. Other studies and news reports highlight demands and shortages for dialysis supplies in hard-hit areas.
AKI develops in 40% to 60% of COVID-19 ICU patients, including 20% to 30% who require renal replacement therapy (RRT), nephrologist Michael J. Connor, Jr, MD, Assistant Professor of Medicine at Emory University School of Medicine in Atlanta, stated in the webinar. Multiple factors may contribute to AKI in a COVID-19 patient, he said. Patients may become dehydrated even before hospitalization because they have not been eating or drinking, have diarrhea, and are battling fever. Aggressive diuresis can induce hypovolemia. “Acute tubular necrosis” (ATN) may ensue from a cytokine storm and respiratory failure. There are also anecdotal reports of glomerular or vascular involvement. Low perfusion or venous congestion can follow cardiogenic shock with low ejection fraction or high positive end-expiratory pressure (PEEP) in mechanically ventilated patients. Direct viral invasion of the renal epithelium as well as nephrotoxicity from some of the experimental COVID-19 therapies are also possible. According to Kianoush Kashani, MD, MSc, of Mayo Clinic in Rochester, Minnesota, AKI is much more likely in the setting of acute respiratory distress syndrome (ARDS).
Early AKI management should focus on determining true volume status using physical examination, passive leg raise, pulse-wave analysis, and point-of-care ultrasound with the goal of returning the patient to euvolemia, Dr Connor stated.
The indications to start RRT are similar to other patients with AKI, according to an ASN recommendations statement. Some early reports suggest that delayed RRT initiation is safe, but this remains controversial. Loop diuretics may be used in the management of volume overload, per the treating physician’s discretion.
On general hospital floors, hemodialysis nurses can conduct intermittent hemodialysis in individual negative pressure rooms or for several COVID-19 patients isolated on one floor provided electronic monitoring is nearby.
For COVID-19 patients in the ICU, the preferred RRT modalities are continuous renal replacement therapy (CRRT) and prolonged intermittent renal replacement therapy (PIRRT), according to ASN. In cases of high demand, ASN suggested using CRRT machines for prolonged intermittent treatments (eg, 10 hours instead of continuous) with higher flow rates (eg, 40-50 mL/kg/h) and then using the machine for another patient, after terminal cleaning.
Optimal vascular access appears paramount, according to Dr Connor and Emory HealthCare guidelines. COVID-19 infection seems to induce a hypercoagulable state and CRRT circuit clotting has been occurring frequently, he noted.
With respect to dialysis supplies, several countries report shortages. Similar reports have recently come out of New York City, where institutions are requesting more continuous dialysis machines, filters, pre-mixed fluids, and tubing. Fresenius Medical Care North America announced it is assembling a national pool of 150 dialysis machines that can be deployed and redeployed to US hospitals in need. Baxter also announced it is maximizing production of its CRRT machines, fluids, and sets.
Recommendations on the care of hospitalized patients With COVID-19 and Kidney Failure Requiring Renal Replacement Therapy. American Society of Nephrology; March 21, 2020.
Fresenius Medical Care North America unveils national intensive renal care reserve in response to COVID-19 [news release]. Fresenius; April 17, 2020.
Baxter shares progress on increasing dialysis supplies for critically ill COVID-19 patients [news release]. Baxter; April 20, 2020. Accessed on April 22, 2020 at https://www.baxter.com/baxter-newsroom/baxter-shares-progress-increasing-dialysis-supplies-critically-ill-covid-19
Mahase E. Covid-19: Increasing demand for dialysis sparks fears of supply shortage. BMJ 2020; 369 doi: 10.1136/bmj.m1588
Owermohle S, Eisenberg A. US races to stock up on dialysis supplies as kidney failure ravages virus patients. Politico; date April 15, 2020. Accessed on April 22, 2020 at https://www.politico.com/news/2020/04/15/dialysis-kidney-coronavirus-188840
Abelson R, Fink S, Kulish N, Thomas K. An overlooked, possibly fatal coronavirus crisis: A dire need for kidney dialysis. New York Times; April 18, 2020 and updated April 20, 2020. Accessed on April 22, 2020 at https://www.nytimes.com/2020/04/18/health/kidney-dialysis-coronavirus.html
Doctors at hard-hit hospitals say they’re facing shortage of dialysis equipment. NPR; April 19, 2020. Accessed on April 22, 2020 at https://www.npr.org/2020/04/19/837727691/doctors-at-hard-hit-hospitals-say-theyre-facing-shortage-of-dialysis-equipment